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Misbehavior or misalignment? Examining the drift towards bureaucratic box-ticking in Competency-Based Medical
Alicia C Strand1, Andrea Gingerich2, Vijay John Daniels1
1Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Plos One
|January 2, 2025
Summary
Competency-based medical education (CBME) residency programs face a bureaucratic "tick-box" approach in Entrustable Professional Activity (EPA) assessments. Residents and faculty develop workarounds to navigate system obstacles, suggesting a need for assessment design modifications.
Area of Science:
- Medical Education
- Workplace-Based Assessment
- Qualitative Research
Background:
- Competency-based medical education (CBME) utilizes Entrustable Professional Activities (EPAs) for learning and promotion.
- Studies note adverse effects like bureaucratic "tick-box" behaviors in EPA implementation.
- Drivers of this bureaucratic drift remain unclear.
Purpose of the Study:
- To explore resident and faculty experiences with EPA processes.
- To identify factors contributing to a "tick-box" approach in EPA assessments.
- To understand how users navigate EPA assessment systems.
Main Methods:
- Qualitative description methodology used.
- Interviews conducted with 16 residents and 27 preceptors post-EPA assessment.
- Data analyzed thematically to identify user experiences and motivations.
Main Results:
- EPA assessments function as currency, acknowledging clinical work.
- Misalignment between prescriptive EPA processes and assessment context creates predicaments.
- Preceptors variably prioritize formative vs. summative EPA purposes.
- Residents and preceptors employ workarounds to overcome system obstacles.
Conclusions:
- Bureaucracy in workplace-based assessments is a predictable implementation pattern.
- User "workarounds" represent rational choices to overcome assessment system obstacles.
- Targeting identified obstacles through design modifications can mitigate bureaucratic drift.
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